Birenbaum-Carmeli and Chassida International Journal for Equity in Health (2021) 20:154 https://doi.org/10.1186/s12939-021-01445-y

RESEARCH Open Access Health and socio-demographic implications of the Covid-19 second pandemic wave in Israel, compared with the first wave Daphna Birenbaum-Carmeli1* and Judith Chassida2

Abstract Background: Israel’s containment of the first wave of Covid-19 was relatively successful. Soon afterwards, however, in the summer months, a harsher pandemic wave developed, resulting in many more seriously ill and dead Israelis. Israel was the world’s first country to impose a second general lockdown. The present study outlines the early months of Israel’s second pandemic wave, until the imposition of the second general lockdown, and their impact on various communities. The investigation is conducted in conjunction with five sociodemographic variables: population density, socioeconomic status, rate of elderly population, minority status (Jewish / Arab identity) and religiosity (Ultra-Orthodox vs. other Jewish communities). Methods: The analysis is based on a cross sectional study of morbidity rates, investigated on a residential community basis. Following the descriptive statistics, we move on to present a multivariate analysis to explore associations between the five aforementioned sociodemographic variables and Covid-19 morbidity in Israel in the early second pandemic wave vs. the first Covid-19 outbreak. Results: Both the descriptive statistics and regressions show morbidity rates to be significantly and positively associated with communities’ population density and significantly and negatively associated with socioeconomic status (SES) and the size of elderly population. These results differ from Wave I morbidity, which was not significantly associated with SES. Another difference vis-a-vis Wave I is the rise of morbidity in Arab communities that led to the disappearance of the previously observed significant negative association of morbidity with minority (Arab) status. Exceptional morbidity was found in Ultra-Orthodox Jewish communities. Conclusion: The second wave of Covid-19 in Israel has profoundly affected marginalized communities characterized by high residential density, low SES and minority status. Other marginalized and disempowered communities have also been badly hit. While acknowledging the potential contribution of various possible causes, we highlight the policy response of Israel’s government during the early weeks of the second Covid-19 outbreak, suggesting that the severe second wave might possibly be associated with belated, undecided government response during this period. Keywords: Covid-19, Morbidity rate, Israel, Socioeconomic status, Population density, Elderly population, Vulnerable populations, Minority, Jewish, Arab

* Correspondence: [email protected] 1Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel Full list of author information is available at the end of the article

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Introduction be contested. We acknowledge this ambiguity but, for Israel’s first case of SARS-CoV-2, hereafter referred to as the sake of reading fluency, continue to use the term Covid-19, was diagnosed in February 27, 2020. On ‘morbidity’ as representative of the number of confirmed March 16, with roughly 60 new confirmed cases a day, a cases. general statewide lockdown was declared. The first wave Our analysis of the spread of morbidity is conducted climaxed in early April 2020, with 500–700 new con- on a residential community basis. Within this fraem- firmed cases a day and a total of less than 10,000 active work, we investigate the association of morbidity rates cases. Mask wearing in public became obligatory on with five sociodemographic variables: population density, April 12th, but was officially enforced, though to a lim- socioeconomic status (SES), percentage of elderly, mi- ited extent, only a couple of months later. From mid- nority status (Jewish/Arab descent) and religiosity. As April, the Covid-19 morbidity started to decline and such, this paper is a sequel of our previous analysis of lockdown restrictions were relaxed. In early June 2020, these associations in Israel’s first wave of Covid-19 [1]. Israel had roughly 2000 active cases and a death toll of The main findings of the previous analysis revealed that less than 300 persons, representing 33 deaths per million in Israel’s Wave I of the pandemic: and a fatality rate of 1.67%, substantially lower than in most West European countries and well below the world – Morbidity rates were significantly and positively average of 6.15% at the time.1 The pandemic was per- associated with population density. ceived as effectively contained. – In the Jewish sector, morbidity rates were However, in June 2020, the number of new confirmed significantly and negatively associated with SES and cases of Covid-19 started to rise, reaching 4000–6000 percentage of elderly population. new cases a day in mid September. The number of – In the Arab sector, SES and percentage of elderly deaths approached 1200 or 130 deaths per million. At population were not significantly associated with this point, with a total of roughly 180,000 confirmed morbidity. cases, 50,000 of which were active, Israel has become the – Arab communities, despite their minority status and world’s most infected country per population. Whereas low SES, sustained significantly lower morbidity severely affected countries like the U.S., India, Spain and than Jewish communities did. France had, at that time, 43, 39, 22 and 10 seriously ill persons per million, respectively, and countries that con- tained the virus more successfully, like Germany, Materials and methods Sweden and Norway had 3, 1 and 0.2 seriously ill pa- This paper is a cross-sectional study, investigating rates tients per million respectively, Israel had 61. From being of morbidity in Israel on a residential community basis. one of the most successful countries to have contained The analysis of Early Wave II figures was conducted in a the pandemic in its initial outbreak, Israel became the similar format to that of Wave I: The dependent variable world’s worst affected country. In September 13, 2020, is Israel’s cumulative Covid-19 morbidity in EWII, span- the government applied a second countrywide lockdown. ning from June 3 to September 13, when a second lock- Israel became the world’s first country to impose a sec- down was declared. Notably, this period does not fully ond general lockdown. capture the second wave, which lasted well into October, In this paper, we look into the pandemic burden but rather, the weeks and months that led up to the sec- through a sociodeographic lens: who were the virus new ond general lockdown. The numbers of confirmed carriers, namely which communities paid the highest toll Covid-19 cases are presented per community and per of the soaring contagion? How was the morbidity in 1000 local community residents. Though the morbidity early wave II associated with communities’ sociodemo- figures heavily depend on the scope of testing, the offi- graphic characteristics? For the sake of clarity, we refer cial daily morbidity count served as a foundational indi- to the period from the pandemic onset in late February cator of local disease spread. As such, it was consistently to June 2, 2020 as ‘Wave I’ (WI) and to the subsequent presented as formative of government decisions and period, from June 3 to the second lockdown in Septem- policy. ber 13 as ‘Early Wave II’ (EWII). Another terminological The sociodemographic variables we explore are those note refers to the term ‘morbidity’. As is well known, we have used to analyze WI morbidity: community many people confirmed as Covid-19 carriers are asymp- population density, SES, percentage of elderly population tomatic. The use of the term ‘morbidity’ may, therefore, and minority status. In addition, in order to refine the results, we subdivided the Jewish sector, distinguishing ultra-orthodox (UO) communities from other Jewish 1https://ourworldindata.org/mortality-risk-covid; identical to extrapolations from https://www.worldometers.info/coronavirus/,on Israelis. (For detailed rationale of choice of variables, see May 28, 2020. [1]) Birenbaum-Carmeli and Chassida International Journal for Equity in Health (2021) 20:154 Page 3 of 12

Data source those published on June 2, 2020 for every community Data was retrieved from Israel’s Ministry of Health Web- that had confirmed cases in it. The statistical analysis site, which presents daily cumulative morbidity figures.2 was performed by Stata software and reflects the differ- In order to calculate EWII morbidity, we reduced the ences and morbidity prediction for this time interval. cumulative morbidity at the end of WI from the total number of confirmed cases in September 13, 2020. The Results difference in the number of communities analyzed in We start the analysis by comparing the distribution of WI vs. EWII represents the difference in the number of morbidity rates in each scrutinized period in Israel by communities with confirmed cases in each of the scruti- community population density (Fig. 1). Each figure de- nized period. The study encompasses all Israeli commu- picts total accumulated morbidity per 1000 persons in nities with Covid-19 cases diagnosed among their each inspected time interval. It is important to note that residents, which amounted to 188 communities. The though we kept the length of the Y-axis in both figures communities were classified by the national/religious identical (due to graphic editing considerations), the Y- identity (Arab/Jewish) of the majority of its residents. axis values changed dramatically from 0 to 15 confirmed Jewish communities were also classified by their level of cases per 1000 in WI, to 0–60 in EWII. religiosity. On the whole, 111 communities were classi- As shown, in both time intervals, morbidity rates were fied as (non-UO) Jewish, 69 as Arab and 8 as UO significantly and positively correlated with population dens- communities. ity, though the correlation somewhat weakened in EWII To supplement this data, we retrieved, for each com- (0.48 vs. 0.23 respectively). This decrease represents the munity, figures from Israel’s Central Bureau of Statistics spread of morbidity in EWII also to low density communi- (CBS), depicting the following variables: community’s ties, as shown in the figure above. Notably, the low density population density (number of residents/ community’s outliers are invariably either Arab or UO communities. area of jurisdiction)3; SES on a 1–10 scale4; Proportion Moving on to the correlation with SES (Fig. 2), we of local population aged > 65 (number of residents older note a change from insignificance in WI, to significant than 65 / community’s total population)5; Minority sta- negative medium power correlation in EWII, suggesting tus (Jewish / Arab; mixed cities were classified by the that in EWII, wealthier communities managed to better majority population, except for Jerusalem, which was an- protect themselves against the virus while poorer ones alyzed in proportion to its Arab/Jewish residents); Religi- became more vulnerable. osity (UO, non-UO.) The correlation thus shifted from negative but insignifi- cant in WI (r = − 0.10) to negative and significant in EWII Method (r = − 0.47, p < 0.05(. The communities with the highest Data is presented in two stages. First, descriptive statis- rates of morbidity (40–60 confirmed cases per 1000), were tics outline the distribution and average figures of the all clustered at the four lowest SES levels (1–4). Five were research variables, with a comparison between the two OU communities and four were Arab communities, which pandemic waves, so as to depict the difference in crude ranked slightly higher than the OU ones. figures. In the second section, a multivariate analysis is In terms of the correlation of communities’ percentage carried out in order to assess the association between of elderly population with morbidity, EWII saw a greatly each variable and a community’s Covid-19 morbidity intensified correlation as compared with WI (Fig. 3). and to outline these relationships in Israel’s population In WI, the crude data revealed no significant correl- in the two pandemic waves. Additionally, the regression ation between a community’s percentage of elderly data about the Jewish sector is used in order to estimate population and its morbidity rates. In EWII, a significant the ‘marginal effect’ of each of the study’s variables on negative correlation was observed, as indicated by the in- local morbidity rates according to the localities’ level of crease of the respective r-values from − 0.07 to − 0.44. religiosity. These data represent the soaring number of confirmed cases in OU communities, where the percentage of eld- Statistical analysis erly people is extremely low: with a fertility rate of 6.6 The statistical analysis is based on the number of aggre- children per woman [2], 58% of the UO population are gate confirmed cases as of September 13, 2020, minus younger than 19 [3]. In this sector, several towns that sustained very high morbidity in WI (Modiin Ilith, Elad, 2https://datadashboard.health.gov.il/COVID-19/general Rechasim and Bnei Brak), were among the most infected 3https://www.cbs.gov.il/he/pages/default.aspx in EWII as well. An additional contribution to the sig- 4 https://www.cbs.gov.il/he/publications/doclib/1999/local_authorities/ nificant negative association is the rise in morbidity in pdf/t02.pdf 5https://data.gov.il/dataset/residents_in_israel_by_communities_and_ Arab communities (e.g., Kafar Bara, Kafar Kasem, age_groups/resource/64edd0ee-3d5d-43ce-8562-c336c24dbc1f Kalanswa and Tira). Though Arab communities are not Birenbaum-Carmeli and Chassida International Journal for Equity in Health (2021) 20:154 Page 4 of 12

Fig. 1 Morbidity rates by community population density, Wave I vs. Wave II as young as OU communities – median ages are 22 and Jewish Israeli communities. The difference emerged as 16 respectively – both these types of communities are formidable. Whereas non-OU Jewish communities had younger than the general country population, whose me- 11.10 confirmed Covid-19 cases per 1000 population on dian age is 35 [3, 4]. The percentage of residents aged average (N = 111), in UO communities (N = 8), the re- over 65 in these most affected communities (Fig. 3, spective figure was 40.19. (t = 11.18, p < 0.05). Though EWII), ranged from 2.5 to 8% of the local population. the number of OU communities is small, the large The correlation of morbidity with minority status has number of confirmed cases indicates that these also changed radically. In WI, as noted above, the mor- communities were significantly more affected than bidity in the Arab sector was significantly lower than in non-UO ones. Jewish communities [1]. In EWII, morbidity rates in Moving beyond descriptive statistics, we probed the Arab communities were significantly higher than in Jew- association of morbidity rates with each inspected vari- ish communities: 18.50 (N = 69 communities) confirmed able and compared the regression models of Israel’s cases on average per 1000 population vs. 13.05 (N = 119) Covid-19 morbidity in the two scrutinized time intervals (significant difference: t = 3.37, p < 0.05). These figures (Table 1). reaffirm the previously noted extensive contagion in Is- The regression highlights several differences: rael’s Arab communities in EWII. Given the prominence of UO communities among the 1. Population density has been significantly and worst affected settlements, we conducted a separate positively associated with morbidity rate in both comparison, distinguishing UO communities from other waves.

Fig. 2 Morbidity Distribution by community SES, Wave I vs. Wave II Birenbaum-Carmeli and Chassida International Journal for Equity in Health (2021) 20:154 Page 5 of 12

Fig. 3 Morbidity by percentage of community elderly population, Wave I vs. Wave II

2. SES was inversely related to morbidity. However, in regression, distinguishing UO from non-UO Jewish WI it was insignificant whereas in WEII, it became communities (Table 2). As shown, when considering significant. An increase in one SES level decreased solely the Jewish sector, the three variables – population morbidityby1.09confirmedcasesper1000(b=− 1.09, density, SES and percentage of elderly population – all β = − 0.22). remain significant. However, UO identity emerges as 3. The percentage of elderly population remained crucial. significantly and negatively associated with In the regression, too, OU communities differed sig- morbidity rate, but intensified in EWII. nificantly from non-UO ones, with 17.4* (3.1) additional 4. Minority status (i.e., being an Arab community) was confirmed cases per 1000, other variables being equal. significantly and negatively associated with Once again, then, morbidity rates in OU communities morbidity in WI, with Arab communities sustaining emerge as much higher than in all others and as the lower probability to morbidity. In EWII, Arab most powerful variable in explaining Covid-19 morbidity minority status lost its statistical significance, as in Israel (β = 0.43). The addition of UO religiosity is also morbidity in Arab communities rose substantially. significant in terms of R2, which explained, after the 5. The model explains roughly similar portions of the addition, 62% of the variance in morbidity in the Jewish variance in morbidity rate in Israel at the sector in EWII, as compared to 37% in WI (when UO community level: 38% in WI vs. 33% in EWII. religiosity was not included in the analysis). Figure 5 graphically depicts the respective regression lines for the The regression lines presented in Fig. 4 graphically Jewish sector. illustrate these EWII trends. Upon concluding, we explored the marginal effect of Because the difference in morbidity between UO and the socio-demographic variables in interaction with UO non-UO communities emerged as so great in the religiosity in Jewish communities in Israel. descriptive statistics, we carried out a Jewish-only Figure 6 presents the predicted probabilities of mor- bidity rate in UO communities vs. other Jewish commu- Table 1 Multilevel Regression Models of morbidity in Israel nities, assuming that the other variables are at average Variables Wave I Wave II values. As seen, UO communities are likely to sustain a coef. (se) β coef. (se) β much higher morbidity at every given level of each of Density 0.00024* (0.00) 0.439 0.001* (0.00) 0.34 the tested variables. To sum up, the regression models revealed the follow- SES −0.122 (0.07) −0.150 - 1.09* (0.47) −0.22 ing changes between WI and EWII: Elderly −9.16* (2.28) −0.343 −69.5* (18.2) −0.37 Minority Status 1.682* (0.39) 0.437 0.46 (1.82) 0.02 1. The significant positive association of (Jews vs. Arab) morbidity with communities’ population e R 0.381 0.329 density persisted. Total (N) 197 188 2. The negative association of morbidity with *p < 0.05 community’s SES intensified and became significant Birenbaum-Carmeli and Chassida International Journal for Equity in Health (2021) 20:154 Page 6 of 12

Fig. 4 morbidity by population density, SES, percent of elderly population and Minority status

in the general country model. (In WI, SES was in Arab communities have risen and even surpassed significant only in the Jewish sector.) those of Jewish communities, though not to a 3. The significant negative association of morbidity significant extent. with the percentage of a community’s elderly 5. Great gap was observed among UO and other population has been maintained and intensified. Jewish communities, with the former suffering 4. The negative significant association of morbidity significantly elevated morbidity rates. with Arab minority status, which was observed in WI, disappeared in EWII, when the morbidity rates Discussion Various reasons can be suggested as underlying the Table 2 Multilevel regression model for morbidity rates in UO steep rise in morbidity in Israel in EWII. The natural and non-UO Jewish communities course of the disease; fast release of WI lockdown; Variables Wave I – Jews Wave 2 - Jews lack of government response to the subsequent rise in coef. (se) β coef. (se) β morbidity; unclear government instructions after WI SES −0.136 (0.07) − 0.14 - 1.26* (0.35) − 0.26 lockdown; breaches of the regulations by senior public ’ Density 0.000* (0.00) 0.46 0.0005* (0.00) 0.21 figures, including the state s President, Prime Minis- ter, Ministers and senior military officers; breaches of Elderly −9.51* (2.44) −0.36 −30.7* (14.1) −0.17 the regulations by ‘rank and file’ Israelis due to eco- UO vs. Non-UO 17.4* (3.1) 0.43 nomic, social and religious pressures; lack of state as- Total 126 119 sistance to people in various forms of need; large R2 0.374 0.619 public gatherings, mostly for religious rituals, espe- *p < 0.05 cially during the holidays, attended by both Jewish Birenbaum-Carmeli and Chassida International Journal for Equity in Health (2021) 20:154 Page 7 of 12

Fig. 5 Wave II – Morbidity rates in the Jewish sector by socio-demographic variables and UO religiosity and Muslim Israelis; ongoing government overlooking the severity of the pandemic during the summer of of these various breaches.6,7 Notwithstanding these 2020. factors, the gap between WI and EWII morbidity was These figures gain additional weight when compared exceptional in Israel. First, the ‘remission’ between the with those of other countries. To this end, we explored two waves was shorter than in other countries, span- the situation in the period of February to September ning roughly along the month of May 2020, vs. 3–4 2020 in several pandemic stricken European countries of months in Germany, or in badly hit Italy and other relatively similar population scale: Norway, Austria, European countries.8 Second, the increase in the se- Sweden and Ireland. Compared to these countries, in verity in EWII was momentous. Whereas the tenfold Israel, the gap between the severity of WI and that of rise in confirmed cases can be attributed to intensi- EWII was wider than in any of the observed countries fied testing, the soaring percentage of confirmed (Case Proportion, EWII/ WI was 8.6 in Israel vs. 1.2–2.2 cases,9 the trebled death toll10 and the death rate, in the other countries), as was the rise in the proportion which quadrupled from 32 per million in WI to 133 of death rates (Death Proportion, EWII/ WI was 3.7 in in EWII, all attest to the swift and stark increase in Israel vs. 1.1–1.3 in the other countries). Given Israel’s exceptionally young population, its island-like situation (i.e., its single international airport), its hot summer 6https://www.maariv.co.il/corona/corona-israel/Article-786852 7https://www.ha-makom.co.il/post-bnei-brak-walk/ months that might have slowed down the virus spread, https://www.idi.org.il/articles/32479 the deterioration is especially alarming, raising questions https://www.haaretz.co.il/health/corona/.premium-1.9198975 regarding the factors that might have underlain it. 8https://www.worldometers.info/coronavirus/ 9 – – Several structural factors seem to have obviously facili- European CDC Situation Update Worldwide Last updated 20 ’ September, Official data collected by Our World in Data tated the disease spread. Israel s population density is ex- 10https://www.worldometers.info/coronavirus/ tremely high, exceeding those of all OECD country, but Birenbaum-Carmeli and Chassida International Journal for Equity in Health (2021) 20:154 Page 8 of 12

Fig. 6 Marginal effect of socio-demographic variables in OU and non-UO Jewish communities in Israel the Netherlands and South Korea.11 High fertility rates August, Israel’s government sustained its exceptionally of over three children per woman, result in large families low level of 34 on the GRSI, while Covid-19 morbidity that often live in small apartments, sometimes, in multi- and mortality were soaring.14 generational families, and are therefore more likely to Notably, between June 29 and August 17, when the suffer from domestic contagion. Some sectors lead trad- number of daily confirmed cases climbed from 800 to itional lives that entail large social gatherings for family 2071, Israel’s government kept lowering the stringency and religious events. In such communities, breaches of of its response from 75 to 34. In the subsequent month, government pandemic dictates were routine. Indeed, re- from August 16 to September 17, Israel’s government luctance towards government restrictions has widened retained its response at a stringency level of 34, lower as the pandemic progressed and gradually included also than that of Sweden, while the number of newly diag- diffused public criticism and countrywide nosed cases trebled from a 7-day average of 1383 to demonstrations.12 4247 and the number of severely ill Israelis climbed by What was the government’s response to these dynam- roughly 50%, from 382 to 573. ics? As mentioned, the government’s strategy has chan- Under these epidemiological and political circum- ged dramatically over the scrutinized period. Starting stances, how did the pandemic spread impact various out from tight lockdown, early on in WI, it moved on to local subpopulations? As revealed by the preceding withdrawal of social restrictions and reluctant enforce- analysis, dense, poor, young communities were espe- ment in EWII. According to the Oxford Government cially infected. Prominent in this category were UO Response Stringency Index (GRSI), based on 18 indica- communities, followed by Arab ones. In UO commu- tors,13 the response of Israel’s government to WI was nities, both the density and poverty have been largely swift and stringent, followed by a gradual relaxation of shaped by the communities’ own preference of excep- restrictions. Interestingly, the government continued to tional fertility rates and low male participation in the reduce the stringency of its response throughout the labor market, due to prioritization of Judaic studies summer of 2020, when the morbidity was steeply resurg- over gainful employment. In the Arab sector, the ing, with daily confirmed cases rising from several dozen crowdedness and poverty were primarily imposed in early June to over 6000 in mid-September. From mid- from the outside by decades of discriminatory state policies that marginalized Arab Israelis in education 11https://data.worldbank.org/indicator/EN.POP.DNST?end=201 and the labor market. During the pandemic, Arab 8&locations=OE&most_recent_value_desc=true&start=2008 communities, that were less intensively supported by If we omit Israel’s Southern desert, that is almost wholly taken up by military bases and training areas, Israel’s density is substantially higher state allowances and foreign charities (compared to than that of these countries as well. UO communities), were economically injured more 12https://www.themarker.com/allnews/.premium-1.9155401, https:// pervasively by the lockdowns (Reznikovski, www.ynet.co.il/article/rJY11QwLBw unpublished). 13https://www.bsg.ox.ac.uk/research/research-projects/coronavirus- government-response-tracker. The indictors are: School closing, Throughout the pandemic, these two sectors were re- Workplace closing, Cancel public events, Restrictions on gatherings, peatedly condemned for conducting large scale social Close public transport, Stay at home requirements, Restrictions on and religious gatherings. Several points need to be noted internal movement, International travel controls, Income support, Debt/contract relief, Fiscal measures, International support, Public information campaigns, Testing policy, Contact tracing, Emergency 14 investment in healthcare, Investment in vaccines, Facial Coverings. https://ourworldindata.org/policy-responses-covid Birenbaum-Carmeli and Chassida International Journal for Equity in Health (2021) 20:154 Page 9 of 12

in this context. First, Covid campaigns in Arab15 and during the pandemic.17 The lack of internet access, due UO16 communities were substantially deficient in the to ideological rejection, impacted UO children, who pandemic early days, as compared to campaigns con- were cut off from their peers and teachers even more ducted in other communities, resulting in belated and than their non-UO peers. Telephone based distant stud- more partial response to the pandemic outbreak. Sec- ies were established but worked rather poorly. ond, the majority of the communities in both sectors In the Arab sector, families and communities sustained abided by the regulations and significant breaching was over 30% of unemployment and unpaid leave from the early observed only in few particular communities. In this re- days of the Covid-19 outbreak in Israel. Following this fi- spect, the public discourse, which often lumped together nancial decline, 42% of Arab families sunk below the pov- ‘the UO’ or ‘the Arabs’ as monolithic entities, was did erty line. Loan applications were, however, mostly declined not do justice to these communities of humble means. by banks and other official lenders, thereby forcing people More generally, both the UO and the Arab sectors in need to withdraw money from pension savings or else have been socially and politically marginalized in Israel’s issue grey market loans. Soon thereafter, people who were public arena for years. The communities’ members live unable to repay their loans and the high interests they in- in their own segregated towns, mostly working in sector- curred, faced lenders’ violent reactions, which were part of ial work places and marrying internally. Even linguistic- a broader, steep rise in rates of local violent crime. In line ally, in the Arab sector and in substantial portions of the with this state of affairs, 30% of Israel’s Arab citizens – UO sector, the spoken languages – Arabic and Yiddish, twice the percent of Jewish Israelis – have reported, during respectively – are not the country’s official language the pandemic, feelings of insecurity, stress, anxiety and de- (which is Hebrew). Politically, too, despite their dramat- pression and described their psychological state as nega- ically different positions in the state’s power structure, tive.18 Children in Arab families, who had insufficient both these sectors have been alienated from Israel’s internet access, could not fully participate in online school- hegemonic Zionist ethos, from the country’s symbolic ing. Domestic violence has also soared. In the first 7 center and its national narrative and are have been rep- months of 2020, 50 Arab Israelis were killed due to vio- resented by their own sectoral parties since the founding lence. Eight of the victims were women. Insufficient police of the State of Israel. Materially, this alienation manifests presence and distrust in its service greatly contributed to also in exclusion from the state’s security bodies. the deterioration.19 Whereas one can dispute the merits of serving in these Problems and strain of various types abounded, how- bodies, participation in any of them is a source of ample ever, also beyond these two sectors. The novelty and material and social benefits, of which both these sectors volunteering that dominated WI gave way to growing are excluded. This separateness has probably contributed routinization, spreading social, psychological and eco- to the communities’ approach that underlay pervasive nomic distress, especially in disempowered settings. Eco- non-adherence to government guidelines during EWII. nomic difficulties and concerns also deepened. In order What were the internal circumstances of the pandemic to assess the scope of the impact, we need to look at the in these sectors? In UO communities, numerous families Israeli landscape before the pandemic outbreak. regularly depend on various types of allowances, most of Israel’s cost of living has been extremely high for years, which have remained intact. These allowances, alongside ranked seventh in the world.20 The mounting prices af- the highly organized community charities that operate fected even the most basic products like food and electri- regularly in the UO sector, have protected many UO city and contributed to growing inequality and class families. However, the closure of the educational system polarization.21 Of all Israeli workers, just over one quarter has brought home many teenage children, who normally (27%) are unionized [5, 6], leaving the rest largely unpro- attend boarding schools, and rendered the small apart- tected. Small business owners and employees are espe- ments even denser than they routinely are. The conges- cially exposed to market fluctuations and have been tion of large families in small spaces increased the risk defenseless in the face of the pandemic-induced commer- of contagion. In some cases, it also flared up domestic cial slowdown. The first wave broke out when less than violence. Though family problems are extremely under- 200,000 Israelis were unemployed. The second wave reported in UO communities, preliminary accounts esti- evolved with nearly 900,000 people on unpaid leave or un- mated that UO domestic violence calls have quadrupled employment benefits. The economic impact was colossal.

15https://www.phr.org.il/wp-content/uploads/2020/10/CovidReport_ Heb_digital-the-real-final-version-compressed.pdf, p. 19. 17https://www.ynet.co.il/judaism/article/HyZ11xzzew 16https://m.knesset.gov.il/activity/committees/petitions/news/pages/% 18https://www.globes.co.il/news/article.aspx?did=1001343428 D7%94%D7%A1%D7%91%D7%A8%D7%94-%D7%A7%D7%95%D7% 19https://fs.knesset.gov.il/23/Committees/23_cs_bg_578017.pdf A8%D7%95%D7%A0%D7%94-%D7%91%D7%9E%D7%92%D7%96%D7% 20https://www.worlddata.info/cost-of-living.php A8-%D7%94%D7%97%D7%A8%D7%93%D7%99.aspx 21https://www.haaretz.co.il/opinions/.premium-1.9248482 Birenbaum-Carmeli and Chassida International Journal for Equity in Health (2021) 20:154 Page 10 of 12

During the pandemic first months, state support to busi- Israel’s Ministry of Education hotline. An official re- nesses was minimal and applied only to particular categor- port assessed that roughly a quarter of Israeli school ies.22 Bureaucratic hurdles made it hard for beneficiaries students experienced stress, loneliness, anxiety, do- to receive these allowances even when they were entitled mestic violence and risk behaviors in EWII.34 With to.23 For many small-scale entrepreneurs, who had taken two thirds of the children reporting inability to par- loans in order to survive the first lockdown and subse- ticipate effectively in online learning, damage was also quent business decline, the scarce state support and then accumulating in the educational sphere. A similar the second lockdown, were fatal. Numerous small busi- proportion of school pupils said they were spending nesses were forced to close down, at first, temporarily and most of the time on their own.35 Children with spe- then permanently [7]. A senior economist estimated that cial needs have been at an even higher risk for vari- some 80,000 businesses, representing a fifth of the coun- ous forms of deterioration and harm.36 try’s businesses, were facing financial collapse, and pre- As elsewhere, elderly people were especially hit by the dicted that hundreds of thousands of workers on unpaid pandemic also in Israel. As of October, the average age leave, will not manage to go back to work.24 The scope of of the dead was 79.5 and the median age was 82. Female the expected economic crisis has been so momentous that victims were slightly older (81.9) than the male (77.6).37 the police has developed plans for tackling the potential As common in Israel, many of the people in this age tide of crime. As part of this forecast, a steep rise was ex- group were accustomed to routine frequent gatherings pected also in the number of new prisoners as well as with family and friends. The pandemic has brought an women who would be forced to turn to sex work.25 At end to these gathering and exacerbated anxiety and that very time, a policy modification allowed company loneliness among many elderly Israelis. In a recent re- owners to distribute exceptional benefits they had been port, half the participating elderly people said they were ‘caging in’ for years, at greatly reduced taxes.26 feeling lonely.38 The number of lone elderly people who Social crises also proliferated. Women, in general, have have died in the pandemic months have risen by 47% as been overrepresented among the pandemic various vic- compared to the previous year (ibid). tims. In September 2020, women comprised 62.7% of People who were subjected to social exclusion before unemployed Israelis or those on unpaid leave, roughly the pandemic were particularly harmed by its spread. twice as men.27 In the private sphere, women in abusive Prisoners had their home and prison visits cancelled and relationships were under greater threat. During the suffered restricted access to healthcare. Given that month of September, domestic violence reports trebled roughly 40% of prisoners are diagnosed with chronic ill- as compared to the previous year.28 In specific time in- nesses and 73% have had previous psychiatric referrals, tervals, the proportion increased five29- to tenfold.30 Be- and given the growing portion of elderly prisoners, the tween March and mid-October 2020, 17 women were health implications of the limitations on care services killed, most of them, by their partners.31 This figure rep- were especially grave in this population.39 People living resents a 50% annual increase vis-à-vis the previous in Israel as undocumented or stateless residents, e.g., decade’s average.32 foreign workers, asylum seekers or Palestinians and tour- Adolescents and young people have also been vul- ists who have overstayed their visas, remained com- nerable to the tide of morbidity. The number of calls pletely vulnerable. Many of these people have lost their to a domestic violence hotline for youths aged 18–20 increased by 500% vs. 2019.33 Tens of thousands of 34 calls from pupils reported psychological distress to https://brookdale.jdc.org.il/wp-content/uploads/2020/05/Children- and-youth-at-risk-and-corona.pdf 35https://haruv.org.il/wp-content/uploads/2018/11/%D7%AA%D7% A4%D7%99%D7%A1%D7%95%D7%AA-%D7%95%D7%AA%D7%97% 22https://news.walla.co.il/item/3373969; https://www.hashikma-rishon. D7%95%D7%A9%D7%95%D7%AA-%D7%A9%D7%9C-%D7%99%D7% co.il/news/38321 9C%D7%93%D7%99%D7%9D-%D7%91%D7%A0%D7%95%D7%92%D7% 23https://www.funder.co.il/article/111577 A2-%D7%9C%D7%95%D7%95%D7%99%D7%A8%D7%95%D7%A1-% 24https://www.haaretz.co.il/opinions/.premium-1.9248482 D7%94%D7%A7%D7%95%D7%A8%D7%95%D7%A0%D7%94-%D7%95% 25https://www.haaretz.co.il/news/law/.premium-1.9250135 D7%97%D7%99%D7%99%D7%94%D7%9D-%D7%93%D7%95%D7%97-% 26https://www.themarker.com/law/.premium-1.9245216, October 19, D7%9E%D7%97%D7%A7%D7%A8-%D7%9E%D7%9B%D7%95%D7% 2020 9F-%D7%97%D7%A8%D7%95%D7%91-%D7%90%D7%A4%D7%A8% 27https://www.haaretz.co.il/news/local/.premium-1.9244015 D7%99%D7%9C-2020-1.pdf 28https://www.haaretz.co.il/news/education/.premium-1.9208324 36https://brookdale.jdc.org.il/wp-content/uploads/2020/05/Children- 29https://www.ynet.co.il/article/BycTg8ivD and-youth-at-risk-and-corona.pdf 30https://www.haaretz.co.il/news/education/.premium-1.8863213 37https://www.haaretz.co.il/health/corona/.premium-MAGAZINE-1. 31https://www.ynet.co.il/article/BycTg8ivD 8730699 32Police data, October 2020 38https://www.globes.co.il/news/article.aspx?did=1001343464 33https://www.tipulpsychology.co.il/%D7%91%D7%9C%D7%95%D7% 39https://www.phr.org.il/wp-content/uploads/2020/10/CovidReport_ 92/domestic-violence-covid-19.html Heb_digital-the-real-final-version-compressed.pdf,p.25–36. Birenbaum-Carmeli and Chassida International Journal for Equity in Health (2021) 20:154 Page 11 of 12

jobs and were not entitled to any financial or logistic of the disease, representing 600 deaths per million. support from the state. Among asylum seekers, about People suffering all forms of disadvantage have been es- 80% have become unemployed. Requests for food, espe- pecially implicated, paying the price of what appeared to cially babies’ food, have doubled, primarily on the part of be a politicized, reluctant government policy that let the single mothers.40 Due to the fear of contagion, the state pandemic take its natural, lethal course. has decided to provide pandemic-related medical treat- ment to these individuals and communities, who are Limitations normally prevented from obtaining medical insurance. The study’s periodization, namely the definition of each This support was, however, minimal and in many cases, of the scrutinized periods, has some limitations. The first ineffective as it had not been planned to match the 41 time interval, February – June 2, 2020, which was ana- needs of the population at hand. In a recent letter to lyzed in the previous article [1], includes the May remis- the heads of state, community activists described how sion period. The second scrutinized interval, June 3– they had managed to survive the first pandemic wave, September 13, 2020, includes the early phase of the sec- with the aid of volunteers and NGOs. However, in EWII, ond wave but not the entire pandemic bout. As such, “the economic and psychological situation of our com- the comparison is not between two ‘full’ pandemic munity is catastrophic. The community is in a state of 42 waves, but rather between the whole initial outbreak and complete uncertainty and helplessness.” the first weeks of the second one. A pandemic is, evidently, a major social, economic and Another limitation refers to the analysis of Israel’s political crisis. As such, it is reflective and formative of mixed cities (e.g., Haifa, Acre, Ramle). These communi- its social context. In Israel, years of underfunding of the ties were classified according to the local majority, i.e., a health and education systems, growing social fragmenta- city with 80% Jewish population was classified as Jewish. tion and economic polarization have preceded the pan- In addition to the smoothing of the statistical analysis, demic. Already before the pandemic, 18% of Israeli this decision was also guided by the (ungrounded) hy- families and 30% of Israeli children lived beneath the pothesis that the minority population that lives in a poverty line. Among Arab Israelis, 45% of families were mixed city might possibly adopt some distinct practices below the poverty line. Poverty among women is 21% that are context dependent. If this is indeed the case, higher than among men. Gini coefficient index is which we cannot substantiate in the present study, then roughly 10% higher in Israel than in developed coun- 43 these particular Arab communities may comprise a tries. These gaps have all surfaced and intensified somewhat distinct subpopulation. We therefore decided when the state has withdrawn from disease containment to sustain a majority-led classification. One exception to following WI lockdown and allowed the pandemic to this rule is the city of Jerusalem, where the Arab resi- further spread. dents are Palestinians from the occupied West Bank and Evidently, the prolonged duration of the pandemic has comprise over a third of the city’s inhabitants. Due to in itself had its impact. Some of the difficulties depicted these distinct characteristics, and because it is Israel’s above piled up in many communities, well beyond Israel. largest city, therefore applying to a larger subpopulation, And yet, the striking differences between the govern- we divided Jerusalem’s residents according to their ment’s policy in the pandemic’s first wave and the early Jewish/Arab identities. second wave suggest that grater government involve- ment and support, as well as stricter enforcement might better protect vulnerable populations, including minor- Conclusion ity, poor and elderly women and men. The very emer- The second wave of Covid-19 in Israel has profoundly gence of the second wave and its exceptional enormity, affected marginalized communities characterized by high may possibly be related to the belated, undecided gov- residential density, low SES and minority status. Other ernment response to the soaring morbidity that placed marginalized and disempowered communities have also Israel far below other island countries that managed to been badly hit. While acknowledging the potential con- contain the pandemic. tribution of various possible causes, we highlight the pol- Israelis were this badly hit by the covid-19 pandemic. icy response of Israel’s government during the early At the time of this writing, nearly 5500 Israelis have died weeks of the second Covid-19 outbreak, suggesting that the severe second wave might possibly be associated 40https://www.haaretz.co.il/news/education/.premium-1.9261655 with belated, undecided government response during 41 https://www.phr.org.il/wp-content/uploads/2020/10/CovidReport_ this period. Heb_digital-the-real-final-version-compressed.pdf,p.38–50. 42https://www.haaretz.co.il/news/education/.premium-1.9261655 43https://www.btl.gov.il/Publications/oni_report/Documents/oni2018. Acknowledgements pdf,P.5. None (N/A). Birenbaum-Carmeli and Chassida International Journal for Equity in Health (2021) 20:154 Page 12 of 12

Authors’ contributions Authors’ contributions: Both authors have developed the paper’s framework. Daphna Birenbnaum-Carmeli has written the paper and Judith Chassida has conducted the statistical analysis. All authors read and approved the final manuscript.

Funding The submitted analysis has not been funded.

Availability of data and materials Sources of data are specified in the manuscript. Declarations

Ethics approval and consent to participate The article is a secondary analysis of government published data and as such did not entail any interaction with participants. It therefore did not require ethics approval or consent to participate.

Consent for publication Both authors consent to submit the paper for publication in the International Journal of Equity in Health.

Competing interests The authors had no competing interests.

Author details 1Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel. 2Department of Education, Herzog College, Jerusalem, Israel.

Received: 17 November 2020 Accepted: 12 April 2021

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